President Obama signed the Clay Hunt Suicide Prevention for American Veterans Act February 12, 2015.

White House official photo by Chuck Kennedy

Originally published on August 27, 2015 11:05 am

Veterans advocates, protesters, and even President Obama have cited the statistic that 22 veterans a day kill themselves. But the reality is complex, and the number can be misleading.

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Jay Price reports on the complexity of statistics about veterans' suicide rates.

A single, deeply-troubling number is shaping the way we think about U.S. veterans: 22.

As in: there are 22 veterans a day who commit suicide. That’s what a VA study announced in 2013.

That simple, easy-to-grasp, and -- in this context -- terrible number has become a rallying cry for veterans groups and activists. But the reality behind it, and what it’s doing to the way we think about younger veterans, isn’t simple.

“That number, if we talk about it out of context, is questionable,” said Keith Jennings, an Iraq war veteran and clinical psychologist who acts as chief science advisor for a Durham, N.C. group called StopSoldierSuicide.org.

Almost weekly, there are walks, swims and runs dedicated to raising awareness of the 22 statistic. In some cities, there have been street-corner rallies on the 22nd of each month. People in California and Texas held 22-kilometer marches, both led by shirtless Marines in shorts carrying packs that weighed 22 kilograms.

There have been lots of news stories this summer about Marine Corps veteran Toby Flaget, who has been walking from Oregon to New Jersey wearing a t-shirt that says, “22 is 22 too many.”

But as it turns out, 22-a-day has little to do with veterans of those wars.

The study that came up with the figure was released in 2012 by the Department of Veterans Affairs Mental Health Services Suicide Prevention Program. While it estimated that 22 veterans died from suicide each day in 2010, it also mentioned some big caveats.

They include the study’s reliance on death certificates to ascertain who was a veteran. States vary in the way they determine a dead person’s veteran status, and the data isn’t precise.

Also, the data was from just 21 states and didn’t include some with large veteran populations. And more than two-thirds of the people in the study who killed themselves were at least 50 years old.

“It is recommended that the estimated number of Veterans be interpreted with caution due to the use of data from a sample of states and existing evidence of uncertainty in Veteran identifiers on U.S. death certificates,” wrote the study’s authors.

Jennings called the study a Herculean effort by great researchers who were clear about its shortcomings.

"This number has some variability within it," Jennings said. "There's some uncertainty in it, and when you talk about this number, it needs to be talked about in context.”

But too many people aren’t using that context, he said.

“When we talk 22 deaths a day, we as Americans think that number, 22, I can hang my hat on it, because it’s a hard number. But it’s not.”

It’s impossible to know if 22 undercounts or over counts veteran suicides, Jennings said, but it’s obvious that mainly it refers to people who didn’t serve in Afghanistan or Iraq.

“And a lot of times, when we talk about that 22 veterans per day, that gets kind of subsumed in this larger conversation or a conversation specific to the current cohort of military service members and veterans, but that is not accurate.”

Psychiatrist Bruce Capehart also raises concerns about the 22-a-day meme. Capehart heads the mental health program for Afghanistan and Iraq veterans at the Durham VA Medical Center. He recently spoke to a North Carolina task force about the complexities of suicide research and the problems with the 22-a-day figure.

Capehart doesn’t dispute the idea of 22 people a day dying, but said it’s unlikely all are veterans.

Instead, he said, based on other research, many of those counted as veterans likely served in reserve units, or were on active duty when they died.

Suicide research complex, challenging

Caveats and imprecision aren’t unusual in research, particularly on suicide, which poses big challenges as a study topic.

Capehart notes that some suicides are recorded on death certificates as accidents, making it impossible to conduct a reliable count of people who take their own lives. And researchers say studies are hard to do with precision because suicides are relatively rare.

“The numbers that happen with suicide are much less than you would get with something like, say, a cold or the flu,” said Department of Defense epidemiologist and statistician Derek Smolenski. “For statistics to be robust and to give you good comparisons and very precise values, you need to have a certain number of people that are falling into the study.”

Smolenski, a civilian who works at Joint Base Lewis-McChord in Washington State, was among the authors of two large suicide studies published this year. One found that veterans who served during the Afghanistan and Iraq wars commit suicide at a rate of about one a day. The other concluded that Americans deployed to those wars were actually less likely to kill themselves than those who served but didn’t go to war.

Smolenski’s research also carries caveats. Among them: it followed Afghanistan and Iraq veterans from their time of discharge until 2009, and its conclusions can’t necessarily be generalized to other time periods.

Which offers a hint into the complexities of suicide research. One plausible theory, say suicide experts, is that combat may not be a serious risk factor for suicide. That could mean the higher rates among older veterans might have little to do with their military service, and instead are tied more to some other demographic trait that they share.

Or, it could be that combat actually does increase risk, but does so later in life.

Smolenski said the studies he was involved with shouldn’t be compared directly with the 22 research.

But, like many suicide researchers, he says he’s become used to seeing results misinterpreted.

“I’m at the point where I shrug it off,” he said. “The popular media will latch onto whatever number they want to and go forth from there.”

A corrosive narrative?

Misinterpreting data, though, could have serious consequences.

Capehart says reliable data on veteran suicide is important for several reasons, including it helps agencies that fund research and prevention decide where to spend their money.

“That helps us focus what should our efforts be as far as outreach, education, prevention and treatment, because most suicides are related to an underlying mental health condition,” Capehart said. “But we have to know who those people are that need those treatments before we can offer it to them and help them become engaged in care.”

Beyond precision with data, there’s another more subtle issue about the figure of 22 suicides a day.

While it has been a valuable tool for drawing more attention to veterans’ issues, some who work with Iraq and Afghanistan veterans worry that it contributes to a corrosive stereotype.

“There’s a narrative that goes something like: American enlists, American goes to war, American comes back and is diagnosed with a mental health condition or is broken, and because they have PTSD, they ultimately kill themselves,” Jennings said. “But that’s a false narrative.”

And it’s not the first inaccurate narrative that Americans have built around a generation of veterans.

Jennings, the son of a Vietnam veteran, grew up surrounded by successful, well-adjusted veterans of that war. Even so, he says, when he thinks about Vietnam vets, his mind reflexively conjures up the cartoonish stereotype of a man on a street corner, begging from a wheelchair with a POW-MIA flag.

This kind of narrative is powerful stuff. And some scientists and veterans advocates fear all the talk of 22 deaths a day, without the caveats, may actually be leading more young veterans to kill themselves.

“That is the thing that scares me about being very overt and talking about it,” said Ilario Pantano, North Carolina’s Director of Veterans Affairs. “Does it legitimize it as a course of action?”

Pantano, also an Iraq combat veteran, says the stereotype can make life harder even for vets who aren’t struggling with mental health problems.

“Potentially it causes an employer to be reluctant to hire a veteran or somebody to be uncomfortable to be in a relationship with a veteran,” he said. “And then that can lead to a negative spiral downstream just because there’s some perception that there’s some fragility or danger associated with that person.

Research on military suicides has increased in recent years. And the VA, Department of Defense, and Centers for Disease Control and Prevention are sharing data to make studies more precise, said Jackie Maffucci, research director for the Iraq and Afghanistan Veterans of America.

Maffucci’s group campaigned to get the Clay Hunt bill passed, and used the 22 statistic while doing so, she said. But it tried to be clear about the nature of that number.

“We tried our best to balance the conversation, in a sense that we never wanted to give the impression that it was 22 post-9/11 veterans because that is just not true,” she said.

“I do think (22) is very important for educational purposes,” Maffucci said. “It’s very important to start the conversation, and it’s a conversation that needs to be had about the challenges within the veteran community, and some of the challenges that are arising with mental health care, with suicide prevention specifically. But certainly there are intricacies to that number.”’

Maffucci said her group’s members consistently say in surveys that suicide and mental health are the issues that most concern them. And though 22-a-day isn’t close to the real number of Iraq and Afghanistan vets who kill themselves, part of the complex reality is that some still do, and at higher rates than the general population.

It’s also true that significant numbers of young veterans suffer problems such as PTSD and traumatic brain injury.

Both Jennings and Pantano know men who served under them in Iraq and killed themselves after coming home. Pantano keeps the photo of one in his office, and he has made suicide prevention and mental health issues priorities for his department.

“What I will tell you is, one is too many,” Pantano said. “One a day is too many.”

But Jennings says people should remember the complex truth about suicide when they meet a young combat vet or hear that 22 statistic.

“What gets lost in the conversation is the majority — actually you can say the vast majority of folks — do okay,” he said. “The vast majority of our veterans do okay.”

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If you or someone you know is at risk of suicide, remember that it is preventable and treatments can help.

Warning signs of suicide:

• Talking about wanting to die

• Looking for a way to kill oneself

• Talking about feeling hopeless or having no purpose

• Talking about feeling trapped or being in unbearable pain

• Talking about being a burden to others

• Increasing the use of alcohol or drugs

• Acting anxious, agitated or recklessly

• Sleeping too little or too much

• Withdrawing or feeling isolated

• Showing rage or talking about seeking revenge

• Displaying extreme mood swings

The more of these signs a person shows, the greater the risk. Warning signs are associated with suicide but may not be what causes a suicide.

What to do if someone you know exhibits warning signs :

• Do not leave the person alone

• Remove any firearms, alcohol, drugs or sharp objects that could be used in a suicide attempt

• Call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255)

• Take the person to an emergency room or seek help from a medical professional